The Effectiveness of an Environmental and Behavioral Approach to Treating Behavior Problems
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Author Affiliations:
Dr. Huh is Associate Director of Education and Evaluation at the VA Palo Alto Health Care System, Geriatric Research, Education, and Clinical Center; Dr. Areán is Associate Professor, Dr. Bornfeld is Staff Psychologist, and Dr. Elite-Marcandonatou is Staff Therapist at the Department of Psychiatry, University
of California, San Francisco.
___________________________
In a Patient with Dementia with Lewy Bodies
Introduction and Background
Dementia with Lewy bodies (DLB) is considered the second most prevalent dementia after Alzheimer’s disease (AD), comprising 15-25% of all dementias.1-3 Core features include dementia, fluctuating consciousness, hallucinations, paranoid delusions, parkinsonism, and neuroleptic sensitivities.2,3 Hallucinations and delusions have been the most diagnostically specific neuropsychiatric symptoms (NPS) distinguishing DLB from AD.4,5 A recent study indicated significant levels of aggressive behaviors on the Cohen-Mansfield Agitation Inventory (CMAI) in patients with DLB,5 with rates similar to that of patients with AD.
Neuropsychiatric symptoms associated with DLB are very upsetting to family and facility caregivers.6,7 NPS leads to poor quality of life for patients and caregivers and contributes to psychiatric morbidity in caregivers if they do not feel effective in managing these symptoms.8 Therefore, finding effective techniques for managing NPS in patients with DLB is a critical goal for clinicians and families.
Managing DLB-related symptoms is complicated.9 Neuroleptic medications are most commonly used to manage agitated behaviors in dementia. However, these medications tend to be less effective in general,10-12 and in patients with DLB are particularly concerning because of their sensitivities to these medications.3,13,14 Behavioral strategies are a viable alternative to medication management.15-18 Successful models combine a behavioral approach, medical consultation, and family involvement. A number of reports suggest that of all the interventions available, behavioral models may be the best available treatments for agitation in patients with general dementia.19 Interestingly, there are no studies or reports that examined these behavioral approaches to address disruptive behaviors in DLB. Symptoms in DLB differ from AD and, therefore, treatment approaches may require further modifications to accommodate these differences.
The purpose of this case study is to provide a descriptive report for professionals caring for persons with DLB and to highlight the need for more evidence-based interventions for treating DLB-related problem behaviors.
Intervention: The Collaborative and Multicomponent Approach
The SBHS was a demonstration project funded by the Substance Abuse and Mental Health Services Administration. The goal of the SBHS project was to develop and disseminate evidence-based treatments of depression and agitation into long-term care facilities. The SBHS collaborated with 10 facilities throughout the San Francisco Bay area. These facilities ranged in size (from 8 to 56 beds) and had staff with varying educational backgrounds (from < 5 years to masters-level nurses and occupational therapists). The SBHS project was developed based on the chronic disease management model.20
This model includes several components:
1. Provider training in the recognition and management of dementia and accompanying NPS which included five training modules and a follow-up training session provided in a group format once a week
2. Consumer and family education about NPS
3. Improved coordination of care through: (a) assessment, (b) treatment tracking and monitoring of patient outcomes to the intervention, and (c) involving professional caregiving staff and family in the development and application of the intervention
4.
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